Chapter 35: Nursing Management: Heart Failure My Nursing Test Banks

Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 35: Nursing Management: Heart Failure

Test Bank

MULTIPLE CHOICE

1. During assessment of a 72-year-old with ankle swelling, the nurse notes jugular venous distention (JVD) with the head of the patients bed elevated 45 degrees. The nurse knows this finding indicates

a.

decreased fluid volume.

b.

jugular vein atherosclerosis.

c.

elevated right atrial pressure.

d.

incompetent jugular vein valves.

ANS: C

The jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the patient sitting at a 45-degree angle reflects elevated right atrial pressure. JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume. JVD is not caused by incompetent jugular vein valves or atherosclerosis.

DIF: Cognitive Level: Comprehension REF: 802

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

2. The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. When evaluating the patient response to the medications, the best indicator that the treatment has been effective is

a.

weight loss of 2 pounds overnight.

b.

hourly urine output greater than 60 mL.

c.

reduction in patient complaints of chest pain.

d.

decreased dyspnea with the head of bed at 30 degrees.

ANS: D

Because the patients major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in dyspnea with the head of the bed at 30 degrees. The other assessment data also may indicate that diuresis or improvement in cardiac output has occurred but are not as specific to evaluating this patients response.

DIF: Cognitive Level: Application REF: 804-806 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

3. Which topic will the nurse plan to include in discharge teaching for a patient with systolic heart failure and an ejection fraction of 38%?

a.

Need to participate in an aerobic exercise program several times weekly

b.

Use of salt substitutes to replace table salt when cooking and at the table

c.

Importance of making a yearly appointment with the primary care provider

d.

Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors

ANS: D

The core measures for the treatment of heart failure established by The Joint Commission indicate that patients with an ejection fraction (EF) <40% receive an ACE inhibitor to decrease the progression of heart failure. Aerobic exercise may not be appropriate for a patient with this level of heart failure, salt substitutes are not usually recommended because of the risk of hyperkalemia, and the patient will need to see the primary care provider more frequently than annually.

DIF: Cognitive Level: Application REF: 812 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

4. Intravenous sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to adjust the nitroprusside rate if the patient develops

a.

a dry, hacking cough.

b.

any ventricular ectopy.

c.

a systolic BP <90 mm Hg.

d.

a heart rate <50 beats/minute.

ANS: C

Sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe hypotension. Coughing and bradycardia are not adverse effects of this medication. Nitroprusside does not cause increased ventricular ectopy.

DIF: Cognitive Level: Application REF: 804-805 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

5. A patient who has chronic heart failure tells the nurse, I felt fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating! The nurse will document this assessment information as

a.

pulsus alternans.

b.

two-pillow orthopnea.

c.

acute bilateral pleural effusion.

d.

paroxysmal nocturnal dyspnea.

ANS: D

Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body areas when the patient is sleeping and is characterized by waking up suddenly with the feeling of suffocation. Pulsus alternans is the alternation of strong and weak peripheral pulses during palpation. Orthopnea indicates that the patient is unable to lie flat because of dyspnea. Pleural effusions develop over a longer time period.

DIF: Cognitive Level: Knowledge REF: 801-802

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

6. During a visit to a 72-year-old with chronic heart failure, the home care nurse finds that the patient has ankle edema, a 2-kg weight gain, and complains of feeling too tired to do anything. Based on these data, the best nursing diagnosis for the patient is

a.

activity intolerance related to fatigue.

b.

disturbed body image related to leg swelling.

c.

impaired skin integrity related to peripheral edema.

d.

impaired gas exchange related to chronic heart failure.

ANS: A

The patients statement supports the diagnosis of activity intolerance. There are no data to support the other diagnoses, although the nurse will need to assess for other patient problems.

DIF: Cognitive Level: Application REF: 810-811 TOP: Nursing Process: Diagnosis

MSC: NCLEX: Physiological Integrity

7. The nurse working in the heart failure clinic will know that teaching for a 74-year-old patient with newly diagnosed heart failure has been effective when the patient

a.

uses an additional pillow to sleep when feeling short of breath at night.

b.

tells the home care nurse that furosemide (Lasix) is taken daily at bedtime.

c.

calls the clinic when the weight increases from 124 to 130 pounds in a week.

d.

says that the nitroglycerin patch will be used for any chest pain that develops.

ANS: C

Teaching for a patient with heart failure includes information about the need to weigh daily and notify the health care provider about an increase of 3 pounds in 2 days or 5 pounds in a week. Nitroglycerin patches are used primarily to reduce preload (not to prevent chest pain) in patients with heart failure and should be used daily, not on an as necessary basis. Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbance. The patient should call the clinic if increased orthopnea develops, rather than just compensating by elevating the head of the bed further.

DIF: Cognitive Level: Application REF: 810-811 | 813

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

8. When teaching the patient with heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include

a.

canned and frozen fruits.

b.

fresh or frozen vegetables.

c.

milk, yogurt, and other milk products.

d.

eggs and other high-cholesterol foods.

ANS: C

Milk and yogurt naturally contain a significant amount of sodium, and intake of these should be limited for patients on a diet that limits sodium to 2000 mg daily. Other milk products, such as processed cheeses, have very high levels of sodium and are not appropriate for a 2000 mg sodium diet. The other foods listed have minimal levels of sodium and can be eaten without restriction.

DIF: Cognitive Level: Application REF: 808 | 809

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

9. The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide (HydroDIURIL). Appropriate instructions for the patient include

a.

avoid dietary sources of potassium.

b.

take the hydrochlorothiazide before bedtime.

c.

notify the health care provider about any nausea.

d.

never take digoxin if the pulse is below 60 beats/minute.

ANS: C

Nausea is an indication of digoxin toxicity and should be reported so that the provider can assess the patient for toxicity and adjust the digoxin dose, if necessary. The patient will need to include potassium-containing foods in the diet to avoid hypokalemia. Patients should be taught to check their pulse daily before taking the digoxin and if the pulse is less than 60, to call their provider before taking the digoxin. Diuretics should be taken early in the day to avoid sleep disruption.

DIF: Cognitive Level: Application REF: 812 | 813 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

10. While admitting an 80-year-old with heart failure to the hospital, the nurse learns that the patient lives alone and sometimes confuses the water pill with the heart pill. When planning for the patients discharge the nurse will facilitate

a.

transfer to a dementia care service.

b.

referral to a home health care agency.

c.

placement in a long-term care facility.

d.

arrangements for around-the-clock care.

ANS: B

The data about the patient suggest that assistance in developing a system for taking medications correctly at home is needed. A home health nurse will assess the patients home situation and help the patient develop a method for taking the two medications as directed. There is no evidence that the patient requires services such as dementia care, long-term care, or around-the-clock home care.

DIF: Cognitive Level: Application REF: 812-814 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

11. Following an acute myocardial infarction, a previously healthy 67-year-old develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about

a.

angiotensin-converting enzyme (ACE) inhibitors.

b.

digitalis preparations.

c.

b-adrenergic agonists.

d.

calcium channel blockers.

ANS: A

ACE inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a myocardial infarction and as a first-line therapy for patients with chronic heart failure. Digoxin therapy for heart failure is no longer considered a first-line measure, and digoxin is added to the treatment protocol when therapy with other medications such as ACE-inhibitors, diuretics, and b-adrenergic blockers is insufficient. Calcium channel blockers are not generally used in the treatment of heart failure. The b-adrenergic agonists such as dobutamine are administered through the IV route and are not used as initial therapy for heart failure.

DIF: Cognitive Level: Application REF: 812 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

12. A 55-year-old with Stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is a possible therapy. Which response by the nurse is appropriate?

a.

Since you are diabetic, you would not be a candidate for a heart transplant.

b.

The choice of a patient for a heart transplant depends on many different factors.

c.

Your heart failure has not reached the stage in which heart transplants are considered.

d.

People who have heart transplants are at risk for multiple complications after surgery.

ANS: B

Indications for a heart transplant include end-stage heart failure, but other factors such as coping skills, family support, and patient motivation to follow the rigorous posttransplant regimen are also considered. Diabetic patients who have well-controlled blood glucose levels may be candidates for heart transplant. Although heart transplants can be associated with many complications, this response does not address the patients question.

DIF: Cognitive Level: Application REF: 814

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

13. Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure?

a.

Serum creatine kinase (CK)

b.

Arterial blood gases (ABGs)

c.

B-type natriuretic peptide (BNP)

d.

12-lead electrocardiogram (ECG)

ANS: C

BNP is secreted when ventricular pressures increase, as with heart failure, and elevated BNP indicates a probable or very probable diagnosis of heart failure. 12-lead ECGs, ABGs, and CK also may be used in determining the causes or effects of heart failure but are not as clearly diagnostic of heart failure as BNP.

DIF: Cognitive Level: Application REF: 803

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

14. Which action will the nurse include in the plan of care when caring for a patient admitted with acute decompensated heart failure (ADHF) who is receiving nesiritide (Natrecor)?

a.

Monitor blood pressure frequently.

b.

Encourage patient to ambulate in room.

c.

Titrate nesiritide rate slowly before discontinuing.

d.

Teach patient about safe home use of the medication.

ANS: A

Nesiritide is a potent arterial and venous dilator, and the major adverse effect is hypotension. Since the patient is likely to have orthostatic hypotension, the patient should not be encouraged to ambulate. Nesiritide does not require titration and is used for ADHF but not in a home setting.

DIF: Cognitive Level: Application REF: 804-805 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

15. A patient with heart failure has a new order for captopril (Capoten) 12.5 mg PO. After administering the first dose and teaching the patient about captopril, which statement by the patient indicates that teaching has been effective?

a.

I will call for help when I need to get up to use the bathroom.

b.

I will be sure to take the medication after eating something.

c.

I will need to include more high-potassium foods in my diet.

d.

I will expect to feel more short of breath for the next few days.

ANS: A

Captopril can cause hypotension, especially after the initial dose, so it is important that the patient not get up out of bed without assistance until the nurse has had a chance to evaluate the effect of the first dose. The ACE inhibitors are potassium sparing, and the nurse should not teach the patient to increase sources of dietary potassium. Increased shortness of breath is expected with initiation of b-blocker therapy for heart failure, not for ACE inhibitor therapy. ACE inhibitors are best absorbed when taken an hour before eating.

DIF: Cognitive Level: Application REF: 806-807 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

16. A patient who has just been admitted with pulmonary edema is scheduled to receive these medications. Which medication should the nurse question?

a.

furosemide (Lasix) 40 mg

b.

captopril (Capoten) 25 mg

c.

digoxin (Lanoxin) 0.125 mg

d.

carvedilol (Coreg) 3.125 mg

ANS: D

Although carvedilol is appropriate for the treatment of chronic heart failure, it is not used for patients with acute decompensated heart failure (ADHF) because of the risk of worsening the heart failure. The other medications are appropriate for the patient with ADHF.

DIF: Cognitive Level: Analysis REF: 807-808

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

17. A patient with a history of chronic heart failure is admitted to the emergency department (ED) with severe dyspnea and a dry, hacking cough. Which action should the nurse take first?

a.

Palpate the abdomen.

b.

Assess the orientation.

c.

Check the capillary refill.

d.

Auscultate the lung sounds.

ANS: D

This patients severe dyspnea and cough indicate that acute decompensated heart failure (ADHF) is occurring. ADHF usually manifests as pulmonary edema, which should be detected and treated immediately to prevent ongoing hypoxemia and cardiac/respiratory arrest. The other assessments will provide useful data about the patients volume status and also should be accomplished rapidly, but detection (and treatment) of pulmonary complications is the priority.

DIF: Cognitive Level: Application REF: 800-801

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

18. A patient with chronic heart failure who has prescriptions for a diuretic, an ACE-inhibitor, and a low-sodium diet tells the home health nurse about a 5-pound weight gain in the last 3 days. The nurses first action will be to

a.

ask the patient to recall the dietary intake for the last 3 days.

b.

question the patient about the use of the prescribed medications.

c.

assess the patient for clinical manifestations of acute heart failure.

d.

teach the patient about the importance of dietary sodium restrictions.

ANS: C

The 5-pound weight gain over 3 days indicates that the patients chronic heart failure may be worsening. It is important that the patient be immediately assessed for other clinical manifestations of decompensation, such as lung crackles. A dietary recall to detect hidden sodium in the diet, reinforcement of sodium restrictions, and assessment of medication compliance may be appropriate interventions but are not the first nursing actions indicated.

DIF: Cognitive Level: Application REF: 801-803

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

19. A patient in the intensive care unit with acute decompensated heart failure (ADHF) complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All these medications have been ordered for the patient. The first action by the nurse will be to

a.

give IV diazepam (Valium) 2.5 mg.

b.

administer IV morphine sulfate 2 mg.

c.

increase nitroglycerin (Tridil) infusion by 5 mcg/min.

d.

increase dopamine (Intropin) infusion by 2 mcg/kg/min.

ANS: B

Morphine improves alveolar gas exchange, improves cardiac output by reducing ventricular preload and afterload, decreases anxiety, and assists in reducing the subjective feeling of dyspnea. Diazepam may decrease patient anxiety, but it will not improve the cardiac output or gas exchange. Increasing the dopamine may improve cardiac output, but it also will increase the heart rate and myocardial oxygen consumption. Nitroglycerin will improve cardiac output and may be appropriate for this patient, but it will not directly reduce anxiety and will not act as quickly as morphine to decrease dyspnea.

DIF: Cognitive Level: Analysis REF: 804-806

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

20. After receiving change-of-shift report, which of these patients admitted with heart failure should the nurse assess first?

a.

A patient who is receiving IV nesiritide (Natrecor) and has a blood pressure (BP) of 100/56

b.

A patient who is cool and clammy, with new-onset confusion and restlessness

c.

A patient who had dizziness after receiving the first dose of captopril (Capoten)

d.

A patient who has crackles in both posterior lung bases and is receiving oxygen

ANS: B

The patient who has wet-cold clinical manifestations of heart failure is perfusing inadequately and needs rapid assessment and changes in management. The other patients also should be assessed as quickly as possible, but do not have indications of severe decreases in tissue perfusion.

DIF: Cognitive Level: Analysis REF: 801

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

21. Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires the most rapid action by the nurse?

a.

Oxygen saturation of 88%

b.

Weight gain of 1 kg (2.2 lb)

c.

Apical pulse rate of 106 beats/minute

d.

Urine output of 50 mL over 2 hours

ANS: A

A decrease in oxygen saturation to less than 92% indicates hypoxemia. The nurse should administer supplemental oxygen immediately to the patient. An increase in apical pulse rate, 1-kg weight gain, and decreases in urine output also indicate worsening heart failure and require rapid nursing actions, but the low oxygen saturation rate requires the most immediate nursing action.

DIF: Cognitive Level: Application REF: 804

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

22. A patient has recently started taking oral digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril (Capoten) for control of heart failure. Which assessment finding by the home health nurse is most important to communicate to the health care provider?

a.

Presence of 1 to 2+ edema in the feet and ankles

b.

Liver is palpable 2 cm below the ribs on the right side.

c.

Serum potassium level is 3.0 mEq/L after 1 week of therapy

d.

Weight increase from 120 pounds to 122 pounds over 3 days

ANS: C

Hypokalemia can predispose the patient to life-threatening dysrhythmias (e.g., premature ventricular contractions), and potentiate the actions of digoxin and increase the risk for digoxin toxicity, which also can cause life-threatening dysrhythmias. The other data indicate that the patients heart failure requires more effective therapies, but they do not require nursing action as rapidly as the low serum potassium level.

DIF: Cognitive Level: Application REF: 807-808

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

23. An outpatient who has heart failure returns to the clinic after 2 weeks of therapy with carvedilol (Coreg). Which of these assessment findings is most important for the nurse to report to the health care provider?

a.

Pulse rate of 56

b.

2+ pedal edema

c.

BP of 88/42 mm Hg

d.

Complaints of fatigue

ANS: C

The patients BP indicates that the dose of carvedilol may need to be decreased because of hypotension. Bradycardia is a frequent adverse effect of b-adrenergic blockade, but the rate of 56 is not unusual with b-blocker therapy. b-adrenergic blockade initially will worsen symptoms of heart failure in many patients, and patients should be taught that some increase in symptoms, such as fatigue and edema, is expected during the initiation of therapy with this class of drugs.

DIF: Cognitive Level: Application REF: 807-808

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

24. A patient who is receiving dobutamine (Dobutrex) for the treatment of acute decompensated heart failure (ADHF) has the following nursing actions included in the plan of care. Which action will be best for the RN to delegate to an experienced LPN/LVN?

a.

Evaluate the IV insertion site for extravasation.

b.

Monitor the patients BP and heart rate every hour.

c.

Adjust the rate to keep the systolic BP >90 mm Hg.

d.

Teach the patient the reasons for remaining on bed rest.

ANS: B

An experienced LPN/LVN would be able to monitor BP and heart rate and would know to report significant changes to the RN. Teaching patients, making adjustments to the drip rate for vasoactive medications, and monitoring for serious complications such as extravasation require RN level education and scope of practice.

DIF: Cognitive Level: Application REF: 805-806

OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

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